F0880

D

Failure to Use Required Gown Under Enhanced Barrier Precautions During Wound Care

Kaufman, Texas Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during wound care. A male resident with multiple diagnoses, including a stage IV pressure ulcer to the left calf present on admission, diabetes, osteoarthritis, and coronary atherosclerosis, was care planned for EBP. The care plan specified that staff must use a gown and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. The resident’s MDS indicated he was usually able to understand and be understood by others and had a BIMS score of 11, indicating moderate cognitive impairment.

During an observation, the Treatment Nurse performed wound care on this resident without donning a gown, despite EBP personal protective equipment (PPE) being available outside the room. The nurse knocked, explained the procedure, performed hand hygiene, opened supplies, and wore gloves, but did not put on a gown while removing the old dressing, cleansing the wound, and applying new dressings. After completing the procedure, the nurse disposed of trash, removed gloves, and performed hand hygiene. In an interview, the Treatment Nurse acknowledged that residents with wounds required EBP, including gowns and gloves, and stated she did not wear the gown because it “slipped her mind.” The DON confirmed that EBP was required for residents with chronic wounds and that EBP for wound care always included a gown and gloves, with goggles or face shield if splashing was anticipated. The facility’s EBP policy stated that EBP is an infection control intervention using targeted gown and glove use during high-contact resident activities to reduce MDRO transmission.